1. Georgi, Kristen


Advanced directives are the key to artful care.


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Decisions about end-of-life care pose complex challenges for patients and their families. In patients with dementia, these decisions become even more complex. Because the final days of patients with dementia are characterized by eating difficulties and malnutrition, along with other functional impairment and infections, the use of feeding tubes is common, despite a body of literature showing that they aren't effective in improving clinical outcomes or survival. Moreover, many of the feeding tubes placed in nursing home residents with dementia are inserted during hospitalization for acute care.

Figure. Milton Bever... - Click to enlarge in new windowFigure. Milton Beveridge, right, visits his wife, Barbara, who has late-stage Alzheimer"s disease, in her nursing home room in Atco, New Jersey. Beveridge, who lives in an adjacent assisted-living facility, had to make the decision to put Barbara on a feeding tube. Photo by Noah Addis / The Star-Ledger.

In an effort to understand why feeding tubes continue to be frequently used, researchers looked for associations between tube placement and a number of factors: hospital characteristics, such as the number of beds, ownership status ("profit, not-for-profit private, not-for-profit church, or government"), graduate medical school residency training, and medical school affiliation; hospital practice patterns, including intensive care use in the last six months of life among all patients with serious chronic illness, the ratio of specialists to full-time primary care physicians, and the use of hospice services; and characteristics of the residents themselves. They analyzed data from 280,869 admissions between 2000 and 2007 from 163,022 nursing home residents ages 66 and older with advanced cognitive impairment at 2,797 acute care hospitals. Feeding tubes were inserted in 19,847 patients.


In-hospital feeding tube use varied widely, from 0 to 38.9 insertions per 100 admissions. One hospital practice pattern in particular, higher rates of ICU use in the last six months of life among chronically ill patients, was associated with a greater likelihood of tube insertion, as were greater hospital size and for-profit ownership, although the reasons for the increased likelihood couldn't be determined. Some patient characteristics were also associated with a greater likelihood of tube insertion, including black race (which nearly doubled the likelihood; white residents were least likely to undergo tube insertion), a history of stroke, and poorer cognitive performance scores. Those facilities that didn't use feeding tubes tended to be smaller, rural, and not affiliated with a medical school; ICU use in the last six months of life among chronically ill patients also tended to be lower at those facilities.


Researchers also found that lower rates of feeding tube insertion were associated with the use of advanced directives, do-not-resuscitate orders, and orders to forgo artificial hydration and nutrition. This highlights the importance of advanced care planning in making end-of-life choices and reducing unnecessary procedures. Although the study doesn't mention alternative feeding methods for these patients, hand feeding by nursing staff must be considered as an option.


"Feeding a patient with dementia-or any patient at the end of life-is a true art," said Pat Gibbons, former head of the nursing section of the National Council of Hospice and Palliative Professionals. "It allows us to be present for such patients, whether they're aware of us or not. It is gentle care. There's a place for feeding tubes-in people who need to be physically nourished after gastrointestinal surgery, for example-but for the dying, our being present is key."


Kristen Georgi


Teno JM, et al. JAMA 2010;303(6):54450.